LA cardiac pt 2 Flashcards
cardiogenic shock CO, SVR, systolic/diastolic
pcwp
decreased CO and increases SVR
systolic
PCWP increased
etio of cardiogenic shock
cardiac d/s: MI, myocarditis, valve dysfunction, congenital hrt disease, CM, arrhythmias
avoid what in cardiogenic shock
tx
aggressive IV fluid tx.
inotropic support: dobutamine, epi
s/s of cardiogenic shock
severe respiratory distress
cool, clammy skin
best LDL lowering drugs
statins! bile acid sequestrants
best meds to lower TG
fibrates! niacin
best meds to increase HDL
Niacin! fibrates
lipid meds for type 2 DM
statins, fibrates
common valve for endocarditis
mitral>atrial>tricuspid>pulm
organism for endocarditis: nml valves/tx
st. aureus
nafcillin or oxacillin plus either ceftriaxone or gentamycin
vanco if needed
organism for endocarditis: abnormal/damaged valves/tx
dental procedures
st viridans
?
organism for endocarditis: IV drug users /tx
st aureus or MRSA
vanco
organism for endocarditis: prosthetic valves/tx
staph epidermis
vanco+genta+rifamin
fungal for endocarditis: tx
amphoteracin B 6-8 weeks
great gm + coverage
PCN and vanco
great gm- coverage
gentamycin and ceftriaxone
immunologic phenomena (4)
for endocarditis
osler’s nodes, roth spots, +RF, acute glomeronephritis
vascular and embolic phenomena in endocarditis (4)
janeway lesions, septic arterial or pulm emboli, ICH
endocarditis test to order first
more sensitive
TTE
TEE
endocarditis prophylaxis and what procedures
2 gm amox 30-60 min before procedure or clinda 600 if allergic
dental, respiratory, infected skin
pericarditis 2 most common causes
idiopathic and viral(coxsackievirus and echovirus)
pericardial friction rub heard best how
end expiration, upright, leaning forward
tx for dressler syndrome
aspirin or colchicine
avR shows knuckle sigh
pericarditis
electrical alternans
pericardial effusion
most common non traumatic cause of tamponade
malignancy
pulsus paradoxus
> 10 mmHg decrease of systolic BP with inspiration
S/s of tamponade
cool extremities, reflex tachycardia, peripheral edema, dyspnea, fatigure, shock
cool extremities, reflex tachycardia, peripheral edema, dyspnea, fatigure, shock
S/s of tamponade
tamponade echo
pericardial effusion + diastolic collapse of cardiac chambers
square root sign on echo
constrictive pericarditis
early diastolic dip followed by a plateau of diastasis.
constrictive pericarditis leads to restriction of what
affects which side of heart
ventricular diastolic filling
right
constrictive pericarditis HF signs
right: JVD, kussmaul, increased hepatojugular reflex, N/V, peripheral edema
constrictive pericarditis tests
sensitivity
CXR
echo (rule of restrictive CM), square root sign
CT/MRI: more sensitive: pericardial thickening
pulsus paradoxes
drop > 10mmHg of systolic BP with inspiration: pericardial tamponade and constrictive pericarditis
electrical alternans seen in what
pericardial effusion
EKG in acute pericarditis
diffuse ST elevations(concave) in precordial leads with PR depressions in same leads, T wave inversions, resolution
avR: ST depression and PR elevation
AAA, what size is nml and aneurysmal
1.5cm and 3.0 cm
AAA most common site
infrarenal
RF for AAA
smoking(main modifiable), age>60, caucasian, male, hyperlipidemia, atherosclerosis, connective tissue d/o, syphillis, HTN
AAA protective factors
female, DM, non caucasian, moderate alcohol consumption
describe aortoenteric fistula with AAA
presents as acute GI bleed in pts who underwent prior aortic grafting
best test for AAA
best initial test: CT with contrast, only do in symptomatic hemodynamically stable pts
abd u/s for asymptomatic pts to monitor progression
symptomatic hemodynamically unstable pts AAA
focused bedside U/S
AAA screening
ages
3-4 cm
4-4.5 cm
>4.5 cm
>5.5 or >0.5 cm
- one time screening via u/s in men 65-75
3-4 cm: u/s every year
4-4.5 cm: u/s every 6 months
>4.5 cm: vascular surgeon referral
>5.5 or >0.5 cm: immediate surgical repair, even if asymptomatic
aortic dissection definition and most common 2 sites
high mortality where
tear through the innermost layer of the aorta intima due to cystic medial necrosis
ascending most common near the aortic arch of left subclavian (65%); descending 20%
ascending is high mortality
3 types of aortic dissection (Debakey)
type 1: originates in ascending aorta propagates to at least the aortic arch and often beyond it distally
type 2: originates in and confined to ascending aorta
type 3: originates in descending aorta and rarely extends proximally but it will extend distally
BP and pulse with aortic dissection
unequal BPs in each arm, decreased peripheral pulses
if aortic dissection is ascending, what new murmur is heard
AR
aortic dissection imaging
CT angiogram most common first line.
CXR will show wide medialstinum: classic.
aortic dissection Stanford 2 types
A. involves ascending aorta and/or aortic arch, and possible descending aorta (anterior CP)
B: involves descending aorta(distal to the left subclavian artery origin), without involvement of ascending aorta and/or aortic arch
describe PAD and ischemic rest pain
in advanced disease, most common at night and relieved with foot dependency
PAD skin on exam
atrophic: atrophy, thin/shiny, hair loss, thickened nails, COOL limbs, areas of necrosis. *lateral malleolar ulcers
NO EDEMA
skin: atrophic: atrophy, thin/shiny, hair loss, thickened nails, COOL limbs, areas of necrosis. *lateral malleolar ulcers
NO EDEMA
PAD
color of limb pale on elevation, dependent rubor
PAD
dusky red with dependency
dusky red with dependency: limb color
PAD
PAD dx test
gold standard
ankle brachial index most useful screening test.
nml is 1-1.2
positive if ABI< 0.90; 0.50 if severe. rest is <0.4
gold standard is arteriography
ABI >1.2
calcified vessel, may lead to false reading
describe acute arterial occlusion
location
vascular emergency, most common is thrombotic occlusion (with preexisting PAD).
most common in superficial femoral artery. (or popliteal)
PAD vs PVD
- oxygen
- shape of wounds
- temp of leg
- edema
- skin color
- pain
PAD: oxygen problem, round red sores, pale/cold, NO EDEMA, sharp pain
PVD: not oxygen problem, irregular shaped sores, warm leg, EDEMA pooling, yellow/brown, dull pain
6 Ps for arterial occlusion
pain, pallor, paresthesias(often early), pulselessness, poikothermia, paralysis(late finding associated with worse prognosis).
arterial occlusion workup
bedside arterial doppler, CT angiography quicker.
arterial occlusion tx
reperfusion; thromboembolectomy
unfractionated heparin and fluid resuscitation for supportive tx
distal extremity ischemia both upper and lower extremities, raynaud’s phenomenon, superficial migratory thrombophlebitis
buerger’s disease, thromboangiitis obliterans
small and medium vessel vasculitis
buerger’s disease, thromboangiitis obliterans dx testing
abnormal allen test
aortography: corkscrew collaterals
bx: segmental vascular inflammation
corkscrew collaterals
buerger’s disease, thromboangiitis obliteran
most common primary cardiac tumor, location
atrial myxoma, 80% occur in left atrium
“ball valve” obstruction of mitral orifice mimicking mitral stenosis on transesophageal echo
atrial myxoma
triad of embolic phenomenon, MS like sx, flu like sx
atrial myxoma
prominent S1, low pitched diastolic murmur
atrial myxoma or MS
only shock with increased PWCP
cardiogenic
only shock with increased CO
septic
2 shocks with increased SVR
cardiogenic and hypovolemic
only shock with decreased HR
neurogenic
electrical alternans, cardiac tamponade
3 sign, coarctation
